who consultation on positive synergies between health systems and global health initiatives

22
WHO Consultation on Positive Synergies between Health Systems and Global Health Initiatives Jim Yong Kim M.D., Ph.D. Jim Yong Kim M.D., Ph.D. Fran Franç ois Xavier Bagnoud Center for Health and Human Rights ois Xavier Bagnoud Center for Health and Human Rights Brigham and Women’s Hospital Brigham and Women’s Hospital Harvard Medical School Harvard Medical School Harvard School of Public Health Harvard School of Public Health Partners In Health Partners In Health May 29 May 29 th th , 2008 , 2008

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WHO Consultation on Positive Synergies between Health Systems and Global Health Initiatives. Jim Yong Kim M.D., Ph.D. Fran ç ois Xavier Bagnoud Center for Health and Human Rights Brigham and Women’s Hospital Harvard Medical School Harvard School of Public Health Partners In Health. - PowerPoint PPT Presentation

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Page 1: WHO Consultation on Positive Synergies between Health Systems and  Global Health Initiatives

WHO Consultation on Positive Synergies between Health Systems and

Global Health Initiatives

Jim Yong Kim M.D., Ph.D.Jim Yong Kim M.D., Ph.D.FranFranççois Xavier Bagnoud Center for Health and Human Rightsois Xavier Bagnoud Center for Health and Human Rights

Brigham and Women’s HospitalBrigham and Women’s HospitalHarvard Medical School Harvard Medical School

Harvard School of Public HealthHarvard School of Public HealthPartners In HealthPartners In Health

May 29May 29thth, 2008, 2008

Page 2: WHO Consultation on Positive Synergies between Health Systems and  Global Health Initiatives

Key Questions

• Health systems and Global Health Initiatives- the state of affairs

•Are there positive synergies between GHIs and HSS?

•Are these synergies being vigorously exploited to assure maximum, mutual added value?

• The need for systematic evidence

• Are there knowledge gaps and, if so, can they be identified?

• How best can current experience be mapped using existing evidence?

• What research is needed to develop the evidence base?

• The search for a logical framework for investigation

• Can we develop appropriate research methodology?

• Can we construct a logical framework for investigation ?

Page 4: WHO Consultation on Positive Synergies between Health Systems and  Global Health Initiatives

Peru (TB Control)

The Peruvian National TB Program

Page 5: WHO Consultation on Positive Synergies between Health Systems and  Global Health Initiatives

SCALE-UP THE PROGRAMMATIC MANAGEMENT OF MDR TB AND XDR TB

2. FINANCIAL SUPPORT FOR MDR TB TREATMENT EVOLUTION

Lima and Callao + 7 regions

Partners in Health

Government Resources

Global Fund

2001-2004

85.2 %

Lima and Callao

2008

98.7 %

Expecting inclusion of 5 more regions

2005-2007

97.0 %

0%

20%

40%

60%

80%

100%

2001 2002 2003 2004 2005 2006 2007 2008

1. GEOGRAPHICAL EXPANSION OF MDR TB TREATMENT

Source: NTP Ministry Of Health Peru

Page 6: WHO Consultation on Positive Synergies between Health Systems and  Global Health Initiatives

HIV/AIDS Prevention and Treatment Strengthens Healthcare System

Partners In Health’s Experience in Haiti

• Because of abandoned health structures, AIDS case detection and treatment impossible without revitalizing health systems.

• GFATM money (and later PEPFAR) used to provide primary health services based on linkages to 4 basic areas

i. HIV/AIDS prevention and care linked via opt out testing to comprehensive primary health care

ii. TB diagnosis and treatment linked with HIV case finding

iii. STD case finding and treatment linked with HIV prevention and testing

iv. Women’s Health Services linked to providing pMTCT and care for women with HIV

Page 7: WHO Consultation on Positive Synergies between Health Systems and  Global Health Initiatives

7

Rwanda District Health System Strengthening Framework

… ProvinceDistrict Leaders & Partners Briefing Session…, .. April 2008

Page 8: WHO Consultation on Positive Synergies between Health Systems and  Global Health Initiatives

The AIDS Support Organization (TASO)

Joint Clinical Research Center (JCRC)

Uganda

Page 9: WHO Consultation on Positive Synergies between Health Systems and  Global Health Initiatives

TASO Joint Clinical Research Center

• Supported by PEPFAR

• US Partner: CDC- public health focused

• Community-based model

• Add’n Services: Counseling, Home-based follow up, Food support, Vocational training

• Results:

i. 2500 patients in ~18 months

ii. Required to attend adherence counseling sessions

iii. Free Medication; $0.30 user fee

• Focuses on keeping patients on treatment

• Supported by PEPFAR

• US Partner: USAID- development focused

• Medical center-based model

• Distribution of ARVs is the key

• Results:

i. 19,000 patients in ~18 months

ii. Expanded to >30 clinics in public health facilities

iii. Cost of treatment: $16/ month

iv. Free ARVs to ~2000 orphans and pregnant women

• Now- Expanding strategies such as home visits to address adherence

• Focuses on Financial independence

Page 10: WHO Consultation on Positive Synergies between Health Systems and  Global Health Initiatives

Global Health “Strategy” To Date

• Countries and even districts working in isolation• Project-based

– Donor preference driven– Experimental pilots that never scale

• Competition among implementers• Cottage-industry approach• Fragmentation of services• Ineffective and not results oriented• Absence of technology and measurement

orientation• Resources diverted for overhead and consultants

Clear need for a better approach

Page 11: WHO Consultation on Positive Synergies between Health Systems and  Global Health Initiatives

“Maximum, mutual added value”

• The need for holistic framework that incorporates all activities and actors contributing to global health outcomes at individual patient and health system level

Value: Patient outcomes per dollar spent

Page 12: WHO Consultation on Positive Synergies between Health Systems and  Global Health Initiatives

The Care Delivery Value Chain

• The care delivery value chain captures:– Interaction between interventions and

infrastructure– The configuration, sequence and

interdependence of interventions– Value is created across the activities during the

“care cycle”

Allows careful examination of all activities of a care delivery system and more thoughtful deployment of resources

Page 13: WHO Consultation on Positive Synergies between Health Systems and  Global Health Initiatives

DELAYING PROGRESSION

DIAGNOSING & STAGING

INITIATING ARV THERAPY

PREVENTION & SCREENING

ONGOING DISEASE MANAGEMENT

MANAGEMENT OF CLINICAL DETERIORATION

INFORMING & ENGAGING

ACCESSING

MEASURING

PATIENT VALUE

(Health outcomes per unit of cost)

• Prevention counseling on modes of transmission on risk factors

• Explaining approach to forestalling progression

• Explaining diagnosis and implications

• Explaining course and prognosis of HIV

• Explaining medical instructions and side effects

• Counseling about adherence; understanding factors for non-adherence

• Explaining co-morbid diagnoses

•End-of-life counseling

• HIV testing

• TB, STI screening

• Collecting baseline demographics

• HIV testing for others at risk

• CD4+ count, clinical exam, labs

• Monitoring CD4+

• Continuously assessing co-morbidities

• Regular primary care assessments

• Lab evaluations for initiating drugs

• HIV staging, response to drugs

• Managing complications

• HIV staging, response to drugs

• Regular primary care assessments

• Meeting patients in high-risk settings

• Primary care clinics

• Testing centers

• Primary care clinics

• Clinic labs

• Testing centers

• Primary care clinics

• Food centers

• Home visits

• Primary care clinics

• Pharmacy

• Support groups

• Primary care clinics

• Pharmacy

• Support groups

• Primary care clinics

• Pharmacy

• Hospitals, hospices

• Connecting patient with primary care

• Identifying high-risk individuals

• Testing at-risk individuals

• Promoting appropriate risk reduction strategies

• Modifying behavioral risk factors

• Creating medical records

• Formal diagnosis, staging

• Determining method of transmission

• Identifying others at risk

• TB, STI screening

• Pregnancy testing, contraceptive counseling

• Creating treatment plans

• Initiating therapies that can delay onset, including vitamins and food

• Treating co-morbidities that affect disease progression, especially TB

• Improving patient awareness of disease progression, prognosis, transmission

• Connecting patient with care team

• Managing effects of associated illnesses

• Managing side effects

• Determining supporting nutritional modifications

• Preparing patient for end-of-life management

• Primary care, health maintenance

• Initiating comprehensive ARV therapy, assessing drug readiness

• Preparing patient for disease progression, treatment side effects

• Managing secondary infections, associated illnesses

• Identifying clinical and laboratory deterioration

• Initiating second- and third-line drug therapies

• Managing acute illnesses and opportunistic infection through aggressive outpatient management or hospitalization

• Providing social support

• Access to hospice care

HIV/AIDS CARE DELIVERY VALUE CHAIN

Page 14: WHO Consultation on Positive Synergies between Health Systems and  Global Health Initiatives

20080221 Wharton GHD – DRAFT 20080221.ppt

INTEGRATING DELIVERY SYSTEM AND CONTEXT

ECONOMIC

DEVELOPMENT

TECHNOLOGY

HOUSING

TRANSPORT

Environmental Factors

Water & Sanitation

Nutrition

Access to Care Facilities

Education

MalariaMalaria

Shared Delivery Infrastructure

HIV/AIDS

TUBERCULOSIS

MATERNAL, PERINATAL CARE

MALARIA

Page 15: WHO Consultation on Positive Synergies between Health Systems and  Global Health Initiatives
Page 16: WHO Consultation on Positive Synergies between Health Systems and  Global Health Initiatives

Next Round of Cases Next Round of Cases

1. MDR-TB/DOTS Plus in Peru

2. Malawi National ART Program

3. ABE: Artemisinin Producers

4. ACTs in Senegal

5. CHAI Pediatric HIV Drug Program

6. Novartis Coartem Program

7. ARV Logistics in Zambia (CIDRZ)

8. Brazil National HIV Program (A&B)

9. Thailand and Quality Improvement

10.Zambia National Malaria Program

11.Bangladesh: BRAC Urban TB

12.Bangladesh: BRAC Rural TB

13.HR and Task Shifting in Swaziland: Male Circumcision

14.PMTCT in Botswana

15.Open MRS

16.Tobacco Control in South Africa

17.Rwanda Mutuelle Program

18.PEPFAR Authorization

19.Tanzania Bed Nets

20.TASO/Uganda’s National HIV Program and the Global Fund

21.XDR-TB in South Africa

22.Plumpy’nut

Page 17: WHO Consultation on Positive Synergies between Health Systems and  Global Health Initiatives
Page 18: WHO Consultation on Positive Synergies between Health Systems and  Global Health Initiatives

•Gathering clinic and system-level data•Interviewing key constituents•Building costing models

Case Studies

Simulation Model

Value Chain Analysis

Analytic Frameworks

for HS building blocks

Monitoring

Delivery Models and Supply

Chains

Implement

Evaluation

Preliminary Framework to Investigate the Interactions between Global Health Initiatives and Health Systems

Epidemiology

Anthropology

Economics

Systems Engineering

StrategyOperationsManagement

Operations Research,

System Optimization

Page 19: WHO Consultation on Positive Synergies between Health Systems and  Global Health Initiatives

Communities of Practice

• Tool to Drive Strategy

• World Bank uses COP as knowledge management strategy

• Quick Problem Solving

• Rapid exchange of information and recommendations

• Generate Innovative Ideas

• Capitalize on current knowledge and generate new perspectives

• Identify and Transfer/Disseminate Best Practices

• Create a forum for sharing and spreading best practices

• Develop Professional Skills

• Willingness to provide and share information and act as mentors

Page 20: WHO Consultation on Positive Synergies between Health Systems and  Global Health Initiatives

Key Questions

• Health systems and Global Health Initiatives- the state of affairs

•Are there positive synergies between GHIs and HSS?

•Are these synergies being vigorously exploited to assure maximum, mutual added value?

• The need for systematic evidence

• Are there knowledge gaps and, if so, can they be identified?

• How best can current experience be mapped using existing evidence?

• What research is needed to develop the evidence base?

• The search for a logical framework for investigation

• Can we develop appropriate research methodology?

• Can we construct a logical framework for investigation ?

Page 21: WHO Consultation on Positive Synergies between Health Systems and  Global Health Initiatives
Page 22: WHO Consultation on Positive Synergies between Health Systems and  Global Health Initiatives

A Path Forward?

• Gather all existing data and expertise on GHI and HSS

• Build a case library of past and current examples of positive synergies and mutual threats

• Collectively study the data to develop frameworks for investigation of positive synergies and mutual threats (e.g. CDVC, systems analysis)

• Develop a framework for evaluation of the impact of GHI’s on health systems (DDCF)

• Create a community of practice for GHI/HSS

• Make our collective work relevant and immediately helpful to practitioners

• Health for All, finally!